Pregnant women have rights, but enforcing them takes resources.

Paula was six months pregnant and working full time as a shift supervisor at a restaurant. She wanted the option to sit on a stool when business was slow, and she wanted a bigger uniform shirt that fit her growing stomach.

So she brought a doctor’s note, asking for “reasonable accommodations” for her pregnancy.

But that wasn’t what she got.

“They thought it was a big joke,” she said. Her boss read the note, then called over the kitchen manager for a laugh. “I started crying. It was my health, the health of my baby, and I was pregnant. It wasn’t a joke to me,” she said.

As more states like California provide pregnancy-discrimination protections and accommodations, employers are still catching up to the new regulations and learning how to implement such changes. For many pregnant women, navigating these rights can be difficult, with few readily available legal resources. And groups like California’s Legal Aid at Work, who do provide free legal assistance across the state to low-income workers whose rights aren’t being recognized, struggle to reach women, especially those most in need of legal support.

That’s where doctors stepped in.

After the humiliating doctor’s-note experience, Paula was at one of her prenatal appointments at the Zuckerberg San Francisco General Hospital’s (ZSFG) Women’s Health Clinic, when she saw a poster advertising Legal Aid at Work. Instead of going to a lawyer’s office, Paula met with one of the Legal Aid staff attorneys in the Women’s Health Clinic conference room. The same place where she received sonograms and prenatal vitamins was also dispensing legal advice.

Legal Aid at Work took on Paula’s case; director Sharon Terman sent a letter to Paula’s employer citing violations of California’s Pregnancy Disability Leave Act. (Paula asked that Slate use only her middle name because of the ongoing legal settlement). A legal exchange ensued, and a settlement is pending, with monetary compensation for Paula and mandatory training on pregnancy discrimination for the restaurant’s management.

Twice a month, since 2014, Legal Aid at Work sends a staff attorney for appointments or drop-in visits at ZSFG’s Women Health Clinic. “Virtually all women seek prenatal care. In San Francisco, it’s very high, 99 percent. Even nationally, it’s a very high number,” said Julia Parish, a staff attorney with Legal Aid at Work, who often does the bimonthly shifts at ZSFG. “By tying this system to prenatal care, we can get this information into the hands of the women when they really need it,” said Parish. “Women will go to the doctors to take care of their babies even if they don’t take care of themselves.”

Most of the 1,000 women who visit the hospital’s Women’s Health Clinic annually for prenatal care are low-wage workers of color who receive Medi-Cal, the state-based Medicaid program, said Dr. Rebecca Jackson, chief of OB-GYN at ZSFG and a professor at the University of California, San Francisco.

Staying employed is especially important in a state that offers paid leave to new parents. They have to keep their jobs long enough to receive thatbenefit.

Jackson is part of a group of doctors and health care advocates who train other physicians about the power of their doctors’ notes and the legal rights their patients have. The Center for WorkLife Law at UC–Hastings has developed an online doctors’ note writing tool, which will generate specific language that they’ve found leads to better outcomes. Terms like no stress or no physical activity can be overly broad, said the center’s deputy director, Liz Morris. “If an employer says, ‘We can’t provide them,’ then the employee needs to go home,” said Morris. Instead, the notes should describe any necessary restrictions in a very specific, detailed way.

“For our patients, the most important thing is to find a way for her to keep working,” said Jackson. “She keeps her benefits, her salary, and her job.” Staying employed is especially important in a state that offers paid leave to new parents. They have to keep their jobs long enough to receive that benefit.

“A lot of these women face discrimination at work, with pregnancy,” said Tahnee Gantt, a medical social worker at the ZSFG Women’s Health Clinic. “Some women have been fired as soon as they disclosed they were pregnant, or if an employer isn’t willing to make accommodations.”

Before the partnership with Legal Aid at Work, Gantt would have to go through the state Employment Development Department and wait on hold. The number of people on hold would often max out, so Gantt couldn’t even remain on the line. It was so hard to receive an answer by phone, Gantt would send women down to the office, where they’d spend hours waiting to speak to someone. Now, she can refer women to an attorney sitting down the hall.

“Now, I have the confidence and knowledge to educate them fully about their rights and their partners’ rights. We gain information as it’s coming out,” said Gantt. For example, this year, California’s paid leave policy increased the percentage of wage replacement for those taking leave (from 55 percent of wages to 70 percent of wages for the lowest-paid workers) and moved up the time. Now employees can receive their paid benefits on day one of their family leave, rather than requiring a week’s absence before the benefits kick in. Because of the partnership with Legal Aid, Gantt was well-equipped to educate patients about their benefits.

Despite the success of the program, Terman said the legal-medical partnership that focuses on pregnancy and employment in California is an outlier, both among other states in the country and among the types of legal-medical partnerships provided. A 2017 survey report from the National Center for Medical-Legal Partnership shows that only 9 percent of medical-legal partnerships surveyed nationwide said they target services to pregnant women. This month, the American College of Obstetricians and Gynecologists issued a committee opinion, which for the first time urges OB-GYNs to discuss workplace expectations with their working pregnant patients and includes a guide on how to best write and structure a doctor’s note to maximize its impact. Jackson was the primary author, and Morris and Terman served as legal support.

Legal Aid at Work recently received a $300,000 Aspen Grant to explore the feasibility of scaling and replicating this model in other communities around the country. “We plan to produce a toolkit documenting best practices and lessons learned for advocates in other states and regions,” said Terman.

Paula is still on leave from her job. After giving birth to a baby boy in December, she still has the option to return this June. As the pregnancy-discrimination claims are settled, all managers at the restaurant chain will have to undergo pregnancy-discrimination and accommodation training. “When you are pregnant, you’re going through a lot already. If I didn’t stop it, they were just going to do it to someone else who was pregnant,” she said.

And she credits Legal Aid at Work, and that connection she made at ZSFG, with allowing her to keep her job.

“It was so stressful, I wanted to quit,” she said. “Because I got Legal Aid involved, they gave me a ray of light.”

Support for this article was provided by Rise Local, a project of the New America National Network.

Rebecca Gale is a regular contributor to the Better Life Lab and an award-winning journalist covering the nexus of politics and people in Washington. Her work has appeared in the Washington Post, Roll Call, Marie Claire, Cosmopolitan, and Health Affairs, among other outlets.